CRF-Billing Window form

CRF-Billing Window form

Claims Request Form

All Claim Adjustment Requests/ New Claims must be submitted within the 90-day billing period.

Provider Name*

Provider #*

Billing Agency Requesting on Providers behalf

(If applicable)

Submitter information *

Please include submitter name, job title, phone number, and email address.

Member Name*

Member ID #*

Service Code*

Claim #*

Date(s) of Service*

Billed Amount*

Paid Amount *

Please select reason for submitting the request*

Select or enter value

Please select changes or corrections to be made*

Select or enter value

Please specify reason for request*

Please include any supporting documents eg. Remittance Advices, Medicare Vouchers etc.

If multiple claims are included on your request, please include a spreadsheet with all claim numbers

Drag and drop files here or